HomeMy WebLinkAboutPermit Backflow Test 1994-10-4
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SPRINGFIELD
BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: 4?{)~);\\:k-, \) O~ \. Q ~'Q.L~
, ASSESSORS MAP #: \~D'~\ . - TAX LOT #: O~2-
O\INE~ rtf\ \ \ \r- ~S-\.,Q 1 (\ J -
ADDRESS:' ?-A, ~ ~ fM\rr\ ~ '"ONE ., ~l \t1\-~k
CITY: ~~ t~ I ~~lcJj STATE: l Q~ _ZIP: G{ rt..f6
CONTRACTOj\ t ~~~ , {\~ S('6'o ~
ADDRESS: \.>0 \~, lcl.DA PHONE #: <1.33 .l(JLf~
CITY~~\\tiJ\~f)W' -' STATE: l\UOf1m1 } ZIP: at')4.\..
CONSTRUCTION CONTRACTORS REGISTRATION #: ql.~ EXPIRES: I. \'(..qs
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. .
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GN1\TURE "
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DATE
FOR OFFICE USE
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DATE OF APPLICATION: \t) 4-.Q4 ~'~ . ~OB #: ~
RECEIPT #: 'ACf~ ISSUED BY: IJ )\au
TOTAL AMOUNT COLLECTE;: \ \.n . W . -
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